Elite Bronze + Vision + Adult Dental – HMO
Network type: HMO
Coverage tier: Expanded Bronze
Primary care visit: $45 copay
Specialist visit: $115 copay
Urgent care visit: $60 copay
Description
Health Care Plan Details
| Network type | HMO |
| Deductible | $0 per person $0 per person |
| Out-of-pocket max | $9,250 per person $18,500 per family |
| Metal tier | Expanded Bronze |
Visit Copay
| Primary care visit | $45 copay |
| Specialist visit | $115 copay |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $60 copay |
| Emergency room | $2,500 copay |
| Ambulance | 50% coinsurance |
| Hospital stay (facility) | $3,000 copay per Day |
| Hospital stay (physician) | No charge |
| Outpatient procedure (facility) | 50% coinsurance |
| Outpatient procedure (physician) | 50% coinsurance |
| Physical rehabilitation | 50% coinsurance |
Maternitowny and Pregnancy
| Well baby care | No charge |
| Labor, delivery, hospital stay | $3,000 copay |
Pharmacy, Drugs, and Medication
| Generic | $3 copay |
| Brand | $195 copay |
| Non-preferred Brand | $250 copay after deductible |
| Specialty | 50% coinsurance after deductible |
Lab Tests and Diagnostic Procedures
| X-rays | 50% coinsurance |
| Imaging (CT/PET/MRI) | 50% coinsurance |
| Blood work | $60 copay |
Mental and Psychiatric Health Care
| Mental Health outpatient services | $45 copay |
| Psychiatric hospital stay | $3,000 copay per Day |
Health Plan Provider Information
| Health Plan Benefits | https://api.centene.com/SBC/2024/77264NC0020036-01.pdf |
| Drug and medication plan formulary | https://ambetterofnorthcarolina.com/resources/pharmacy-resources.html |
| Search doctor list | https://ambetterofnorthcarolina.com/findadoc |
